Parkridge Christian Academy – Summer Camp Release from Liability

I, the undersigned, hereby grant my child (student’s name) __________________permission to participate in any

Parkridge Christian Academy sponsored activities during summer camp for which I have personally granted

permission by enrolling my child in summer camp at PCA.

By my signature to this statement of permission, I hereby release and hold harmless the above named school and

Parkridge Baptist Church of Coral Springs and the individual sponsors, including teachers, administrators, and

parents from liability, mishap or injury to the student named herein from the start of each camp day until the end of

each camp day. I do not hold them responsible for the loss of personal items.

Permission for Medical Treatment

In the event my child becomes ill or is injured while under school supervision, I approve of the school authorities

taking the following steps:

1. Contact a parent of the student and follow their instructions.

2. In the event neither parent can be reached, contact the student’s physician and follow his instructions.

3. If the student’s physician cannot be reached, the school authorities will use their own discretion in contacting a

properly licensed practicing nurse or physician and follow the instructions.

4. In the event of an emergency the 911 services will be called and then an attempt to notify the child’s parent will

be made.

Consent to Medical Care and Treatment of a Minor: I hereby give permission for my child to be given emergency treatment, to include first aide and CPR by a qualified

staff member of Parkridge Christian Academy. If my child needs medical or surgical services that require my consent

and I cannot be reached, I hereby authorize, appoint, and empower the school authorities of Parkridge to take my child

or contact an ambulance to take my child to a properly licensed and practicing physician. In such case, I waive my

right of informed consent to such treatment.

I hereby release Parkridge Christian Academy and Parkridge Baptist Church and its authorized personnel from any

liability which might arise from the giving of such authorization; it being my desire that my child be given such

medical or surgical services as soon as reasonably possible. I also hereby release Parkridge and its authorized

personnel from any payment due for any and all medical and/or transport services rendered for my child.

Child’s name________________________________________________Grade__________________

Child’s date of birth__________________Child’s Social Security#_____________________________

Medical information___________________________________________________________________

(PLEASE ATTACH A COPY OF YOUR CHILD’S INSURANCE CARD TO THIS FORM)

Parent/Guardian Signature__________________________________________Date_________________________

STATE OF FLORIDA_________COUNTY OF BROWARD___________________________________________

The foregoing instrument was acknowledged before me this _________day of _____________________,20______

By___________________________________________________________________________________________

______________________________________ _______________________________________________ Notary Public, State of Florida My Commission expires

Personally Known_______or produced indentification__________Type of identification______________________

1

Please indicate by checking below the session(s) your child will attend Summer camp

Session I - June 8th – June26th Deposit

Session II June29th – July

17th Deposit

Session III July 20th –

August 7nd Deposit

A $100 nonrefundable deposit, per child and session is required to secure your spot when you turn in this packet.

Child’s Name: _______________________________________________ Starting Date:_____________

Last First

K 1 2 3 4 5

Grade completed:

M/F: __ _Age: ____ DOB:__________Hair Color:__________Height: _______ Weight:_____ Eye Color:

List all of the following that we should be aware of:

Allergies: __________________________________________________________________

Medications:________________________________________________________________

Other Medical conditions: ______________________________________________________

Family Doctor: _____________________________Phone:_______________________

Child Lives with: Both Parents Mother Father Other

Mother’s Name:______________________Home Phone:__________________Cell ______________________

Work Phone :________________________Email Address: ___________________________________

Address Mother:________________________________City___________________ zip code __________

Father’s Name:______________________ Home Phone:__________________Cell ______________________

Work Phone :________________________Email Address: __________________________________

Address Father (if different): ______________________________________________________________

2020 Summer Camp Registration Form Parkridge Christian Academy

5600 Coral Ridge Drive

Coral Springs, FL 33076

Phone: (954)346-0236

Fax: (954)346-0013

2

Initial beside each statement acknowledging you have received read the following

information:

_____ I have received, read and am in agreement with the PCA Camp Handbook and the policies defined

therein.

_____ I understand that payment for the Parkridge Christian Academy Summer camp will be made through the

FACTS system on the date and means I select. Failure to pay on time will result in a late fee and/or dismissal

from the program.

_____ I understand that it is necessary to pick up my child(ren) on time per the hours listed in the handbook.

Failure to do so will result in a late pick up fee ($10.00 for every 5 minute interval) and possible dismissal from

the program.

_____ I understand that it is my responsibility to keep my own records and receipts for income tax purposes.

_____ I have received and read the “Know Your Child Care Facilty” brochure

_____ I give Parkridge Christian Academy my permission to take photos and video of my child during Summer

camp activities.

_____ I understand that my child will have multiple periods of outdoor (weather permitting) physical activity on

the PCA layground or field as determined by the camp staff. Appropriate supervision will be provided. Both

“free play” and organized activity will be part of these times.

The Office of Child Care Regulation has compiled a list of frequently asked questions about your family;

please respond yes or no and explain if necessary, in the last month your child or any one in the family:

Y/N _______ had a fever of 100.4 or higher?

Y/N________ had any respiratory infection, or have had a cough, shortness of breath, and low-grade fever?

Y/N_________ In the previous 14 days, have you or someone in your family had any contact with someone

with a confirmed diagnosis of COVID-19; is under investigation for COVID-19; or is ill with a respiratory

illness?

Y/N________In the previous 14 days, have you or someone in your familly traveled on a cruise or

internationally to countries with widespread, sustained community transmission?___________

Please explain if yes in any of he above questions

_________________________________________________________________________________________

__________________________________________________________________________________________

_

Special Needs Students/Recommendations for Formal Evaluations: Parkridge’s summer camp is not

specifically designed to accommodate special needs students and failure to disclose students’ special needs

(behavioral, physical, emotional, or developmental) can result in immediate dismissal with no refund for

prepaid services. Even failure to disclose dismissal from previously attended camps/aftercare facilities due to

any of the above mentioned reasons may also result in immediate dismissal with no refund for prepaid services.

3

PASSWORD (to be used to identify parent calling to send someone other than those listed below to pick up student on

their behalf):

____________________________________________________________________

People authorized to pick up your child (PU) or act as emergency contact (EC) Circle category.

Name

EC\

PU Relationship Home Phone Cell Phone

EC PU

EC PU

EC PU

Print Parent Name:__________________________________

Parent/Guardian Signature:______________________________ Date:_____________

Camp cover sheet

$50 (non-refundable) registration fee per family

Sibling Discounts: 10% for 2nd and 15% for 3rd

Parkridge Christian Academy Registration papers list. Please check the return to

school line, once papers are turned in add the date to them please.

1. Summer Camp Flyer: For your information

2. CDF influenza brochure: Return back to school _____ ________

3. Know Your Child Care Facility Form: For your information

4. Medical Liability Release Summer Camp: Return back to school _____ ________

(Include a copy of your driver’s license and the school will notarize for you)

5. PCA Discipline Matrix : For your information

6. Student conduct Expectations: Return back to school_____ _______

7. Summer 2020 Covid 19 procedures For your information

8. Summer Camp 2020 Cover sheet: Return to school _____ ________

9. Summer Camp 2020 Registration form: Return back to school _____ ______

10. Summer Camp 2020 Handbook: For your information

11. Discipline Policy and Hours of operation: Return back to school ______ ______

*Any questions or concerns regarding summer camp please email/ Camp Director, Diana Arias at

Darias@parkridgeca.com

Session Session Date Session Price 1 June 8th- June 26th $375

2 June 29th- July 17th $375

3 July 20th- August 7th $375

Parkridge Summer Camp 2020

Camp Hours: 8:00am-5:00pm 954-3460236

3

Student Conduct Expectations

Show Respect

For Others

NEVER leave the room without permission

Listen to and follow instructions: pay attention to your teachers,

do what you are asked to do the first time you are asked

Treat others with kindness: share, take turns, help others, speak

to build others up

For Yourself

Always give your best effort: work to bring glory to God (i.e. assignments,

Bible activities, chapel, sportsmanship, etc.)

Make good choices that you will be proud of: Christ-like example

For Property

Clean up after yourself

Ask permission before using others’ belongings

Label all personal items

Take all of your belongings home every day

I agree to abide by the above stated expectations.

________________________ _______________________

Student’s Printed Name Student’s Signature

________________________ _____________

Parent’s Signature Date

5600 Coral Ridge Drive Coral Springs, FL 33076

Phone (954) 346-0236 Fax (954) 346-0013